Facing Facts: what’s the good of change?

Tony Blair defines the role of Government as creating the conditions in which individuals can pursue fulfilment in their own lives to the fullest extent possible. This evidences a new form of compact between the State and the citizen that is only just coming fully into view – one which at the same time demands that the individual accepts responsibility for taking on risks that in the post war years the State sought to conceal if not remove in the name of a different kind of compact – one in which the State acted as guarantor of the individual. The vicissitudes that the individual is faced with as a consequence reflect distinctly different approaches to what can be expected from the State, in which the UK finds itself somewhere between the USA and continental Europe – but between what? Thought of as a dilemma, the choice is between a presumption of the State knowing versus not-knowing best – a dilemma that in the UK can be seen clearly in the approach being adopted to the reform of the UK’s National Health Service. Within the NHS, both horns of the dilemma jostle for attention through a heady mix of top-down driven versus locally-enabled interventions. Working within this context, what is most striking is what gets ignored in the process of holding steady in the face of such a confusion of directions pressing for change. Understood as a demand for negative capability – the capacity to hold still in relation to ignorance for long enough to allow learning to take place, it requires a capacity for containing anxiety that stretches managers and clinicians alike beyond reason. The question then becomes one of how to render such anxiety bearable in the interests of change. The Lacanian perspective addresses this question in terms of the particular valency that insists between individual phantasy and the organisational architectures of power. The paper will use case material from a major intervention in the UK’s National Health Service that made use of disruptive processes and supporting IT innovation, the aim of which was to put this valency into question in order to bring about change. The paper will explore the ways in which facts were not faced, and a blind eye was turned to the complexity surrounding the improvement of patients’ access to health care. It goes on to consider how these processes for rendering anxiety bearable are replicated more generally within the wider context of society. How is this to be theorised, and what consequences does this have for understanding ‘resistance’? These questions are approached through the presumption that anxiety operates like a geiger counter in bringing manager, clinician and change agent alike to the question of the good of change. This approach mirrors the new form of compact with the citizen, having at its base a changed presumption of the good of anxiety, which constitutes a different basis for authority and leadership. The paper concludes that it is paradoxically in the moments of disobedience to the architectures of power that the good emerges. This presents a new kind of challenge to leadership.